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Pakku-man

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Hello everyone.
Taking money out of the equation (obviously a procedure based specialty will be making quite a bit more than a general internist), do some specialist advertise and practice general internal medicine in the outpatient setting. To emphasize my point, say I specialized into endocrinology. Can I advertise myself as an endocrinologist and as an general internal medicine doctor. Like I'm an "endocrinologist" managing a 400 lb diabetic patient who is on an insulin pump and who sees me for a prostate exam, immunizations, annual physicals, or ambulatory complaints such as back pain?

What are the opportunity costs are associated with such a decision? (granted this is allowed). Here are my assumptions below:
1. Dual boarding (IM and "specialty") - time and money
2. Additional insurance fees? (one for "specialty" other for "IM?")
3. Complicating workflow in the office with your staff.

Bottom Line
1. Can I as a doctor practice both my specialty and general internal medicine in the outpatient setting?
2. What are the opportunity costs with this?
 

gutonc

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1. Can I as a doctor practice both my specialty and general internal medicine in the outpatient setting?
Sure. You can also do Botox or skin biopsies or anything else you are competent/credentialed to do.

2. What are the opportunity costs with this?
Mostly the soul crushing nature of PCP work. The best thing about being a sub-specialist is being able to say "You'll have to take that up with Dr. Primary at your next visit".
 

HelpPleaseMD

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Hello everyone.
Taking money out of the equation (obviously a procedure based specialty will be making quite a bit more than a general internist), do some specialist advertise and practice general internal medicine in the outpatient setting. To emphasize my point, say I specialized into endocrinology. Can I advertise myself as an endocrinologist and as an general internal medicine doctor. Like I'm an "endocrinologist" managing a 400 lb diabetic patient who is on an insulin pump and who sees me for a prostate exam, immunizations, annual physicals, or ambulatory complaints such as back pain?

What are the opportunity costs are associated with such a decision? (granted this is allowed). Here are my assumptions below:
1. Dual boarding (IM and "specialty") - time and money
2. Additional insurance fees? (one for "specialty" other for "IM?")
3. Complicating workflow in the office with your staff.

Bottom Line
1. Can I as a doctor practice both my specialty and general internal medicine in the outpatient setting?
2. What are the opportunity costs with this?

don't do it. you only have so much time in your day.
 
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What about being primarily an endocrinologist but then doing an occasional 2 wks of inpatient general IM here and there, for example?
 
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gutonc

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What about being primarily an endocrinologist but then doing an occasional 2 wks of inpatient general IM here and there, for example?
Who's covering your clinic on those weeks?
 

DrBowtie

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Seems like your endo consults would dry up after you poach everyone's patients.
 
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Raryn

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What about being primarily an endocrinologist but then doing an occasional 2 wks of inpatient general IM here and there, for example?
There are still some academic places that allow subspecialists to act as ward attendings a few times a year. This is getting rarer and rarer though.
 

Pemulis

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1. Can I as a doctor practice both my specialty and general internal medicine in the outpatient setting?
2. What are the opportunity costs with this?
1. Yes, you can do this. Historically, this is what many subspecialty internists did, and I still know a few older guys who do just this, e.g. 50% primary care, 50% cardio/pulm/endocrine/whatever.

2. The opportunity costs are numerous, which is why almost nobody does this anymore. They include but are not limited to: extra years of training which are then only applied part time to your practice, extra overhead for running your office (it usually costs less to run a primary care office than a specialty one due to needing fewer medical supplies), needing a staff that can support both roles, billing/insurance hassles, needing to spend time staying current in two different skill sets, etc.

Currently, there is so much business for physicians in most areas that there's really no economic need to have a combined practice anymore. It's more lucrative to just do one thing well and efficiently.
 

Pemulis

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Sure. You can also do Botox or skin biopsies or anything else you are competent/credentialed to do.


Mostly the soul crushing nature of PCP work. The best thing about being a sub-specialist is being able to say "You'll have to take that up with Dr. Primary at your next visit".
To each their own, but as a PCP, I don't find my work soul crushing at all. In fact, I love my job. I suspect the reason many people perceive PCP work as dull, dispiriting, and poorly compensated is that they only get exposed to residency clinic and/or academic primary care practice during their training. I can assure you that private practice life is actually pretty fun.

Pemulis' rule #463: residency clinic is to primary care what warm and skunked Bud Light is to beer.
 
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IMreshopeful

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To each their own, but as a PCP, I don't find my work soul crushing at all. In fact, I love my job. I suspect the reason many people perceive PCP work as dull, dispiriting, and poorly compensated is that they only get exposed to residency clinic and/or academic primary care practice during their training. I can assure you that private practice life is actually pretty fun.

Pemulis' rule #463: residency clinic is to primary care what warm and skunked Bud Light is to beer.
I'm a budding cards guy but I have to agree with this. Outpatient primary care in the private practice world is way way better than crappy primary care clinic in the inner city academic residency life. It's great for the attendings who can use residents to write all their notes and do their work but it sucks practicing on a day to day basis.
 

IMreshopeful

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What about being primarily an endocrinologist but then doing an occasional 2 wks of inpatient general IM here and there, for example?
I have some clinic attendings who are boarded in endocrine and rheum who also do primary care. Much like I have inpatient attendings who are sub specialists but run general medicine services. I think it's pretty rare overall though.
 

Gastrapathy

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My folks Internist is endocrinology trained. His practice is 50/50. Endocrine and nephrology probably make sense for this, maybe some others. But you wouldn't want me trying to manage the diabeetees.
 

Pakku-man

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Wow! Thank you all for the replies! Please keep em coming if you all have anymore insight. The reason I asked this question is that I wish to engage with a community as both a general internist and as a specialist. For me I find this particularly rewarding to continue a working knowledge of what PCPs do in addition to my "specialty". Also, I would like to surprise my patients like so: "Mr. ______! I am your PCP and you need a rheumatologist! You're in luck! I am one!

@Pemulis thanks for the insight on the opportunity costs. Still wondering if there is a way to set up a practice of likeminded people who feel this way. I am excited with the idea of practicing as a PCP and a specialty. However, with your comment about training staff in two types of medical practices does the same count for Med Peds then? How about Family? Surely for something like rheum and endocrine it wouldn't be that much of a stretch? Pardons in advance if I'm super naive (M4 here)
 

reca12

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@Pakku-man, are you on the interview trail already? Given your interests, I suggest looking into the primary care tracks that many programs now offer in addition to the categorical tracks. I'm similar to you in that I would like to do endo or rheum but may still incorporate primary care in my practice. The faculty in these tracks might be able to help guide your career too in a way that you want. I'm finding that a lot of the primary care tracks offer specific training that's very useful for not just primary care but for any ambulatory-based specialty (how to run a clinic practice, ambulatory QI projects, telephone medicine, panel management, etc.). They also dedicate more blocks for ambulatory time. None of these primary care tracks require you to go into primary care in the end, and most are very open to those interested in something like endocrinology, rheum, palliative care, nephrology, etc. PM me if you would like to know more details.
 
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Pemulis

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@Pemulis thanks for the insight on the opportunity costs. Still wondering if there is a way to set up a practice of likeminded people who feel this way. I am excited with the idea of practicing as a PCP and a specialty. However, with your comment about training staff in two types of medical practices does the same count for Med Peds then? How about Family? Surely for something like rheum and endocrine it wouldn't be that much of a stretch? Pardons in advance if I'm super naive (M4 here)
There's always a way to do pretty much whatever you want. I would assume to some extent it does count for med/peds and family, but one problem you would not have in either of these fields is finding like-minded colleagues to practice with. In other words: if you are FM, it's pretty easy to find other FM people to share a practice with, so call and overhead can be easily distributed amongst your peers. It will be harder to find other endocrinologists who are interested in doing both IM and endocrine, so things can get trickier. Who covers your primary care call if none of your partners do primary care? Who pays the overhead for primary care expenses around the office such as an EKG machine, vaccinations, and spirometry supplies? Conversely, if all of your partners do IM only, who is going to want to pay the salary for a diabetes educator? Who will take your endocrine call for you when your on vacation?

I think the short answer to your question is this: yes, you absolutely can do what you are proposing. But there are valid reasons why most of the medical world has moved away from this model. If you proceed down this path it will come with some costs to your finances and your sanity.

If you're an M4, I'd just focus for now on finding a residency program you like. Train hard and the rest will come a little later.

Good luck.
 

dozitgetchahi

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Wow! Thank you all for the replies! Please keep em coming if you all have anymore insight. The reason I asked this question is that I wish to engage with a community as both a general internist and as a specialist. For me I find this particularly rewarding to continue a working knowledge of what PCPs do in addition to my "specialty". Also, I would like to surprise my patients like so: "Mr. ______! I am your PCP and you need a rheumatologist! You're in luck! I am one!

@Pemulis thanks for the insight on the opportunity costs. Still wondering if there is a way to set up a practice of likeminded people who feel this way. I am excited with the idea of practicing as a PCP and a specialty. However, with your comment about training staff in two types of medical practices does the same count for Med Peds then? How about Family? Surely for something like rheum and endocrine it wouldn't be that much of a stretch? Pardons in advance if I'm super naive (M4 here)
I'll preface this by stating that I'll be starting rheumatology residency in the fall.

Trust me - you're not gonna want to do this. The only internists I hear of that are doing this stuff around here are nephrologists who can't make ends meet doing renal and are supplementing their income with primary care.

There are multiple reasons why such an arrangement is so undesirable:

1. To my knowledge, you can't bill a visit for care in two specialties. This is why 'combined' residencies like IM/neuro and IM/psych are of limited usefulness. It's cool to think you'd have that crossover knowledge, but any primary care pt you see who incidentally happens to have MS or whatever is going to get billed like a primary care pt.

2. Primary care sucks ass. Aside from the one cheery poster above, every single other physician I've met in primary care is utterly miserable - and these are people in community practices. The academic PCPs I've worked with and met are actually *happier* than the community PCPs (but not by much). The poster above must work in Pleasantville.

3. Many subspecialties are in high demand, and waiting lists are long. In the midwestern state I train in, there are no rheumatologists between the big city where I work and the borders to the north and south, respectively (where other big cities exist). Patients were driving 3 hours to the big city for a rheum f/u appt. Some rheumatologist opened a practice in the south and was immediately inundated with patients wanting to make an appointment - he's now booked out 4 months. Doing primary care + rheumatology in this setting makes no sense whatsoever.

4. Many above have listed the concerns with coverage/clinic staff/etc, all of which are relevant.
 

Pemulis

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There are multiple reasons why such an arrangement is so undesirable:

1. To my knowledge, you can't bill a visit for care in two specialties. This is why 'combined' residencies like IM/neuro and IM/psych are of limited usefulness. It's cool to think you'd have that crossover knowledge, but any primary care pt you see who incidentally happens to have MS or whatever is going to get billed like a primary care pt.

2. Primary care sucks ass. Aside from the one cheery poster above, every single other physician I've met in primary care is utterly miserable - and these are people in community practices. The academic PCPs I've worked with and met are actually *happier* than the community PCPs (but not by much). The poster above must work in Pleasantville.

3. Many subspecialties are in high demand, and waiting lists are long. In the midwestern state I train in, there are no rheumatologists between the big city where I work and the borders to the north and south, respectively (where other big cities exist). Patients were driving 3 hours to the big city for a rheum f/u appt. Some rheumatologist opened a practice in the south and was immediately inundated with patients wanting to make an appointment - he's now booked out 4 months. Doing primary care + rheumatology in this setting makes no sense whatsoever.

4. Many above have listed the concerns with coverage/clinic staff/etc, all of which are relevant.

Regarding point 2: I do work in Pleasantville. But then there must be an awful lot of people here, because I have many friends and colleagues in primary care too, and by and large we’re a happy group. I think that a lot of the things people assume about primary care from their residency exposure - lots of paperwork, difficult/drug-seeking/non-compliant patients, tedious and boring office visits, poor pay - just aren’t the norm in a well run private practice. Perhaps such practices don't exist in dozitgetchahi's neck of the woods.

As I said above, to each their own. I’d be suicidal if I had to do Rheumatology all day, but by no means do I believe that other people aren’t perfectly suited to doing Rheumatology for their careers.

I would endorse points 1, 3, and 4 however.
 
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sacrament

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Yeah, you're not actually going to want to do this once you get out there. I realize there are a handful of specialists out there doing it, but it is almost always because of some extenuating circumstance. It sounds good in theory, I get it, but it will make no sense to you once you're entrenched in the real world.
 

jdh71

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Hello everyone.
Taking money out of the equation (obviously a procedure based specialty will be making quite a bit more than a general internist), do some specialist advertise and practice general internal medicine in the outpatient setting. To emphasize my point, say I specialized into endocrinology. Can I advertise myself as an endocrinologist and as an general internal medicine doctor. Like I'm an "endocrinologist" managing a 400 lb diabetic patient who is on an insulin pump and who sees me for a prostate exam, immunizations, annual physicals, or ambulatory complaints such as back pain?

What are the opportunity costs are associated with such a decision? (granted this is allowed). Here are my assumptions below:
1. Dual boarding (IM and "specialty") - time and money
2. Additional insurance fees? (one for "specialty" other for "IM?")
3. Complicating workflow in the office with your staff.

Bottom Line
1. Can I as a doctor practice both my specialty and general internal medicine in the outpatient setting?
2. What are the opportunity costs with this?
Yes. You won't want to. There is currently absolutely ZERO incentive to try and do both, especially with the current compensation models.

You will be more efficient and productive sticking one area you know very well and dealing with only those issues.
 

gutonc

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1. To my knowledge, you can't bill a visit for care in two specialties. This is why 'combined' residencies like IM/neuro and IM/psych are of limited usefulness. It's cool to think you'd have that crossover knowledge, but any primary care pt you see who incidentally happens to have MS or whatever is going to get billed like a primary care pt.
I just want to correct this misconception. There's nothing magical about billing as a subspecialist compared to a PCP when it comes to non-procedural work. It all comes down to the E/M codes and the documentation you have to support that.

As an example, let's say I see a patient who's getting chemo for metastatic lung cancer. He's also got malignant bone pain, chemo induced nausea and constipation. I evaluate and document the management of those 4 things (cancer + chemo, pain, nausea, constipation). I can bill a 99215 (highest basic f/u E/M code) for that, and unless I spend >90 minutes with the guy, that's all I can bill (although I'll often throw in tobacco cessation counseling, sicne you know that dude still smokes, and score a 99406 on top of it).

The next day he goes to see his PCP who manages his HTN, COPD, A fib and DM2. He also bills a 99215 and will get paid the same amount for that visit that I got the day before. Now, if I took over managing his HTN, COPD, A fib and DM2, or the PCP took over managing his nausea, pain and constipation, we'd still both only be able to bill a 99215 (unless, as above, we took over 90 minutes to do that and billed on time, which isn't happening).

This is obviously different for procedural specialties, and I do bill a few bone marrow biopsies a month...but in general it's not worth it.
 
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dozitgetchahi

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The next day he goes to see his PCP who manages his HTN, COPD, A fib and DM2. He also bills a 99215 and will get paid the same amount for that visit that I got the day before. Now, if I took over managing his HTN, COPD, A fib and DM2, or the PCP took over managing his nausea, pain and constipation, we'd still both only be able to bill a 99215 (unless, as above, we took over 90 minutes to do that and billed on time, which isn't happening).
This is what I was trying to get at, although I was a bit unclear about it and/or didn't fully understand all of the implications.
 

gutonc

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This is what I was trying to get at, although I was a bit unclear about it and/or didn't fully understand all of the implications.
It sounded like you thought that sub-specialists are somehow able to bill at a different rate/level than PCPs which is patently false. I bill the same office visit that the dermatologist who doesn't do a biopsy or injection bills (assuming equivalent complexity).

Perhaps what you meant to convey is that you don't get to bill one visit as the sub-specialist and a second (although, exactly the same) visit as the PCP. And that is absolutely correct. But kind of weird.
 
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